Toileting during Dialysis - page 2

by Lynx25

9,620 Visits | 36 Comments

I am currently at a LTC facility, where several of our patients go out 3 times a week for outpatient dialysis. Currently, the facilty we send them to does NOT toilet our patients while they are there. They refuse to assist... Read More


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    When I did chronics, and I worked in more than one unit, it was not unusual to put people on the bedpan or urinal while on dialysis. Not very many needed this because most were anuric and if it was a BM, most would just wait until they got off dialysis, they didn't want to go on a bedpan. On rare occasion we disconnected the ones who could walk to the bathroom but this was highly discouraged for infection control reasons and if they had needles in it wasn't very safe to leave them in, even taped up, when they went to the bathroom (keep in mind these are large bore needles (14 to 15Fr) in very large fistulas or grafts, they will bleed out very quickly). We also cleaned up incontinent patients, but because of the extreme fast pace of this environment, it was not done or checked like it should. I have never seen a staff member come from a LTC just to change a patient; never ever crossed my mind to do consider that. A chronic dialysis unit is like assembly line...get 'em in, run 'em, and get 'em out, unfortunately. Plus the staffing is always short almost everywhere I worked.
    I was able to monitor blood sugars but there was no insulin there, we were not allowed to do any kind of coverage whatsoever. I did have meds to treat hypoglycemia but most units had to food or juice at all for patients. The medications I gave were the typical dialysis meds (epogen, iron, etc) and the only prns we had were Tylenol and sometimes antihypertensive and nausea meds. As for low BPs, that shouldn't be happening, sounds like they need an adjustment to their goal weight.
    VivaLasViejas likes this.
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    I, for one, do not accept PCTs refusing to toilet pts. It is not reasonable for me to be off the floor that long when I have many other pts on the machine; however, I do not mind covering the PCT for the 10-15 min they are off the floor.

    Is it our job to toilet? I'm told it's not, but I would be pretty angry if my mom or dad was left to sit in their own filth for 4 hrs. The one thing that I would ask of LTC nurses is to please make sure you send an extra brief with so that if there is an accident, we have something to change them into. The other thing would be a change of pants.

    As for wipes, the ones we use to wash the chairs and machines with work great with some warm water.

    I do agree with the other dialysis nurses about things like medications or insulin. If your pt has an appt at some other clinic at noon, wouldn't you feed them and give meds such as insulin either earlier or later?

    If pts are coming back with low pressures, this needs to be reported to the dialysis nurse as there are things we can do to help this.
    SE_BSN_RN, MJB2010, and VivaLasViejas like this.
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    Quote from Ashley, PICU RN
    The simple reason is that they are there for dialysis. Nothing else. The nurses don't have orders from the MD to check blood sugar or administer insulin. Nor do they likely keep insulin at the dialysis facility. They are at the dialysis center for a specific purpose- dialysis. Like I said above, it's often not possible for the staff to leave the dialysis center/floor to transfer patients and in some cases the policy at their facility does not allow them to transfer patients. If the patient were to be injured or fall during transfer the facility would be liable. Or the nurse/tech were to be injured while transferring, their workman's comp would not cover it.
    That is neglect, bordering on abuse. Good excuses for a dialysis clinic. Too bad that doesn't fly in LTC. I am surprised patients can't be assisted to the bathroom and helped. What do you tell them if they say they need to go? "No, I can't take you, sorry?" Hmmm. Nice.
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    Quote from VivaLasViejas
    You know, it just struck me that we're all complaining about the same thing---LACK OF STAFFING!! And why is that? Because every area of nursing is understaffed. And why is that?

    You guessed it. MONEY. It's all about the Benjamins, not patient care, and certainly not nurses' ability to do their jobs with adequate supplies, staff, and time. We've got to know healthcare is in ruins when we can park somebody in a dialysis chair for 4 or 5 hours and let them sit in their own waste because there aren't sufficient staff members available to toilet them.

    What a cluster-mug. It's stuff like this that turns nurses against each other. How much longer are we going to take it without fighting back?
    YES YES YES!! Finally SOMEONE gets it! But one call to a state health department on a complaint about someone at dialysis sitting in their own waste for 4 hours may change the course of those dollars!
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    It is not possible. As a tech or nurse you have a 3 patient assignment, with my clinic there vitals are taken every half hour and before and after tx. We dont let patients leave with a BP less than 100. There is no physical way we can change a patient. Like one of ours who doesn't move, she just lays there, our chairs that they sit in do not fit in the bathroom and we our facility does not have the necessary supplies to toilet the patiets, not to mention there is no time in the day!
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    1. Changing pts or allowing them to use a urinal/bedpan while on dialysis is clearly an infection control issue - this is one big room, no privacy of any kind.

    2. Using the cloths that are used to disinfect chair/equipment often contain bleach and they are surely not supposed to be used to clean an incontinent pt.

    3. The bathrooms in dialysis units are very often not large enough to assist pts. Hoyer lifts will NOT fit in any of the bathrooms of the units where I go.

    4. Comes down to quality of life: if the pt is incontinent, unable to indicate when they need to go (so that they can be disconnected and walk to the bathroom), maybe its time to have a "is this worth it" talk.

    5. I work in some very rural clinics and a very large, inner city clinic. The NH will come occasionally to clean a pt up.


    Other solutions: if Mom or Dad is incontinent and can't get to the bathroom by themselves, they need a family member or sitter provided by the NH to come and stay with them (in the waiting room). Many of my pts have sitters provided by the NH - I do have a high percentage of pts that are mentally ill and so cannot be expected to cooperate with dialysis unless someone sits by them and holds their hand and/or encourages them to sit still, not pull at their needles, etc..
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    Quote from lvn2bsoon
    That is neglect, bordering on abuse. Good excuses for a dialysis clinic. Too bad that doesn't fly in LTC. I am surprised patients can't be assisted to the bathroom and helped. What do you tell them if they say they need to go? "No, I can't take you, sorry?" Hmmm. Nice.
    One of the role of LTC is to assist the resident with ADL's. So of course it wouldn't fly for staff to say they wouldn't do something that is central to their function as a facility. MJB2010 wrote an excellent post about why it's not always possible to toilet a patient during dialysis.

    I'm not sure what would be said to the patient, because I've never been in the situation. I do know that administration tends to make policies that don't seem very well thought out or practical in the real world. (Such as liability while transferring patients.) But if we wish to keep our jobs, these are things we need to adhere to- or escalate the situation to get the policy changed.

    For example, when I was a CNA in LTC, our facility was attached to some independent living apartments. It wasn't an ALF, but the apartments had emergency call buttons in case someone were to fall or be sick or injured, etc. If an emergency button was pushed, the policy was to send a CNA from the facility to the apartment to check on the occupant. We were given a "kit" with a master key, gloves, some bandaids, a phone, and I don't remember what else.

    Here's the kicker- we were not allowed by administration to do anything except call 911 and stay with the occupant if they needed help. We could not assist them up if they had fallen (understandable). We could not perform CPR, according to our policy, if we found a person in arrest. We were told that if we did these things while on the time clock, our actions would not be covered by our employer.

    Fortunately, I never was faced with the situation where I found an occupant in serious distress or arrest. I'm not sure what I would have done. I'd like to think I would have performed CPR anyway, despite the facility's policy, and risked my job and possibly CNA certification. But that's a life or death situation for the victim. Would I risk my job at an outpatient dialysis unit to bring a 300lb, two-person assist patient to the bathroom?
    kaliRN likes this.
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    The sad fact is that it is the policy at the dialysis clinic to not toilet patients. The clinic cannot spare staff to do this. The pace is frantic, staff is not authorized to do any lifting, it is an infection control issue and a safety issue. Neglect bordering on abuse? Okay. But go ahead and try to get either facility to go along with that mind set far enough to make sure there is enough staff available to take responsibility for it on either end and see what happens. As someone said very eloquently, we have been thrown into an impossible situation. Blaming, finger pointing and fighting will get us nowhere. We should join together and find ways of changing policies so that we can give better patient care.
    VivaLasViejas likes this.
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    I can't figure out how to multiquote....sorry.

    Quote from lvn2bsoon
    That is neglect, bordering on abuse. Good excuses for a dialysis clinic. Too bad that doesn't fly in LTC. I am surprised patients can't be assisted to the bathroom and helped. What do you tell them if they say they need to go? "No, I can't take you, sorry?" Hmmm. Nice.
    I agree! However I also have to agree that it can be a huge infection control risk not to mention that PCTs are not all trained in proper tranfers, etc.

    2. Using the cloths that are used to disinfect chair/equipment often contain bleach and they are surely not supposed to be used to clean an incontinent pt.
    In my clinc, the wipes do not contain any chemicals until they are put in bleach water. They are large, heavy duty, and very soft.

    It is not possible. As a tech or nurse you have a 3 patient assignment, with my clinic there vitals are taken every half hour and before and after tx. We dont let patients leave with a BP less than 100. There is no physical way we can change a patient. Like one of ours who doesn't move, she just lays there, our chairs that they sit in do not fit in the bathroom and we our facility does not have the necessary supplies to toilet the patiets, not to mention there is no time in the day!
    It is possible, it's called teamwork. Someone can cover you while you take a pt to the restroom.

    Trauma,

    While I completlely understand where you are coming from I just cannot do it. If someone throws up all over themselves don't the staff find a way to clean them up or change their shirt? I guess I see it as the same. Unfortunately, these patients do not always get to choose when they dc dialysis becuase it is their family that is holding on and has the power to make that decision. I know it's not right, and if I could change their minds I would, but that is a process that often takes a long time. I feel that even if they are at that point, we need to do our best to ensure quality of life until the end finally comes...but that's a topic for a different thread.

    For those of you who say that it is not possible and there is not enough time in the day....I work in a 26 chair, inner city unit with many patients in wheelchairs. Our schedule is grueling and as a nurse, I have 24 pts with no other nurse and only 5 PCTs until 0900 everyday. After that, we add one more nurse and one more PCT. We find time. We work together to make time. We cannot enlist the help of family or LTC staff because we do not allow visitors (we had issues with drug deals in the unit and had to change to a no visitor policy).

    I really do get where you all are coming from. The last thing you want when you are in the middle of turnover and have your schedule worked out so tight that a deviation of 3 minutes can through your day off, is someone asking to use the restroom. The only thing that keeps me from saying no is thinking about what I would want for myself and my family.
  10. 1
    In our facility it is mainly an infection control issue. Most of our LTC pts are diapered. And it is rarely a problem. A few times we had the patients family come clean the patient. But we do not have the supplies on the unit because it put the other patients at risk for infection. So it is more involved than you think. It is not just lazy
    Staff or whatever. LTC is where the patients live and reside. Of course the expectations are higher.
    Natkat likes this.


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